Three Cases of Local Anesthetic Systemic Toxicity following regional infiltration analgesia: The need for prompt recognition and treatment
Kevin A. S. Carroll*, Jonathan Henglein, Paul Boland, Paul Gallagher, Kermaan Mehta, Sabatino A. Leffe, Oktay Shuminov, Alejandro Betancourt-Ramirez, Shannon F. R. Small
Department of Surgery, South Shore University Hospital, Northwell Health, Long Island, New York, USA
Introduction: The diagnosis and management of systemic toxicity in patients following regional infiltration analgesia is of paramount importance. While the mechanism and risk factors have been elucidated in previous studies, we believe that due to the potentially life-threatening nature of this rare occurrence, a greater focus on diagnostic precision and management enhancements is warranted.
Cases: Here, we describe three cases of LAST, the first in a 59 year old female following elective L4-L5 laminectomy and L5-S1 fusion, who suffered a cardiac arrest after receiving local Exparel and Marcaine at the time of closure; the second in a 69 year old woman following a rib block using local Exparel and Marcaine for the management of multiple rib fractures, who had a witnessed tonic-clonic seizure requiring intubation. The third patient is an 80-year-old male, who after an elective L4-L5 laminectomy and fusion, suffered a cardiac arrest after receiving local anesthetic (Exparel and Marcaine) at the time of closure. All patients were treated with intralipids and eventually recovered with no lasting deficits.
Conclusion: LAST events most commonly occur in the first minutes after injection, and are characterized by CNS and cardiovascular toxicities, as seen in these patients. Delayed presentations up to several days post exposure have been described. These cases exposed the opportunity for education in early recognition and most important, the need to improve the availability of intralipids. Prompt recognition and access to intralipid is critical to the treatment of LAST, and education regarding this rare but life-threatening condition is needed in surgical and trauma centers.
DOI: 10.29245/2768-5365/2023/2.1144 View / Download PdfTreatment of Pain Revisited ‐ The argument against too rapid resort to narcotic analgesics in Emergency Departments in Australia
Roy G. Beran1,2,3,4,5*
1South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
2Ingham Institute, The Liverpool Hospital, Sydney, Australia
3School of Medicine, Griffith University, South Port, Queensland, Australia
4School of Medicine, University of Western Sydney, Sydney, NSW, Australia
5Sechenov Moscow First State University, Moscow, Russia
Introduction: Pain is a common neurological complaint with many patients already taking narcotic analgesics at presentation to the neurologist. This paper examines an approach to pain management aimed to avoid narcotic analgesics.
Clinical Practice: Pain is subjective and may be considered as either acute or chronic pain, differentiated between pain provoking avoidance or pain without benefit. Pain management is determined by the underlying diagnosis and clinical status.
Use of Narcotic Analgesics: Narcotic analgesics have the potential for abuse and pose public health risks. Abuse has increased among street and recreational drug users. The Australian Government restricted access to combination codeine containing medications, requiring a prescription and medical supervision.
Discussion: While there exist specific pain syndromes, the use of narcotic analgesics should be judicious. Their use should be restricted to refractory pain but should not exclude their legitimate use, once alternative remediation has been exhausted and entails medical supervision.
Conclusion: Narcotic analgesics should not be the first line treatment for pain, with initial approach directed towards diagnosis and treating the underlying cause. Once refractory chronic pain has been established, narcotic analgesics should be available under medical supervision, acknowledging the risk of overuse and addiction.
DOI: 10.29245/2768-5365/2023/2.1142 View / Download PdfPericapsular Nerve Group Block in Hip Surgery: A Narrative Review
Daniela Bravo1, Rousmery Atton2,3, Diego Mora1, Julián Aliste1,3*
1Department of Anesthesiology and Perioperative Medicine, Hospital Clínico Universidad de Chile, University of Chile, Santiago, Chile
2Department of Anesthesiology, Pontificia Universidad Católica de Chile, Santiago, Chile
3Department of Anesthesiology, Clínica Las Condes, Santiago, Chile
Study Objective: This narrative review discusses the anatomy, mechanism of action, techniques, indications and complications of the pericapsular nerve group block in a hip surgery setting.
Interventions: The MEDLINE, EMBASE and Google Scholar databases (inception to the first week of March 2023) were searched. For anatomy, mechanism of action, techniques, and complications, cadaveric research, randomized trials, retrospective studies and case series were considered. Nonetheless, for surgery indications, to highlight the best evidence available, only randomized trials without major discrepancies with their prospective registration, blinded assessment and sample size justification were retained for analysis.
Main Results: The anatomical studies suggest that pericapsular nerve group block may work through a combination of different mechanisms (i.e., blocking lateral capsule nerves, local anesthetic spread to the femoral nerve, spread towards medial capsule nerves). Compared to alternatives, except for the periarticular local anesthetic infiltration, pericapsular nerves group block results in similar or improved postoperative analgesia in total hip arthroplasty. It should be noted that the motor blockade has not been completely circumvented and the scarcity of adequate studies on other surgical procedures prevents from obtaining further conclusions about its indications.
Conclusions: The pericapsular nerve group block has become very popular after its first description as an analgesic motor-sparing technique for hip fractures. However, without an absolute motor-sparing effect, its current indication is better supported in postoperative analgesia for total hip arthroplasty. Therefore, further investigation is required to find the optimal motor-sparing analgesic block for hip surgery.
DOI: 10.29245/2768-5365/2023/2.1141 View / Download Pdf